There are people that think that we could have much faster medical progress via a basically libertarian approach: decrease or abolish government regulation of drug development. Or permit companies to market new drugs without first proving that they work.

Nutritional and herbal supplements are barely regulated at all: so by this argument there should be all kinds of medical progress stemming from that area. But it hasn’t happened. supplements are mostly useless, yet people buy them anyhow. There’s very little regulation of medical developments in third world countries – why aren’t they a a fount of medical progress? But that’s an unfair comparison: we know why they’re not.

So why is drug development harder than making a better cellphone or laptop?

People are complicated, evolved rather than designed, product of a recipe rather than a spec. We know something about human biochemistry and physiology, but far from everything. We know enough that some ( a few) of our new ideas about treating disease work – but most don’t, including most of those that everybody involved just knew had to work. It’s fair to say that we don’t have a good interface spec.

Next, the consequences of failures can be considerably more serious. The equivalent of the blue screen of death is .. death. Developing a new drug is more like developing avionics than apps: we don’t want planes to crash, and we’ve succeeded – but not through a unregulated market.

Knowing some history gives perspective. In 1900, few of the drugs in the pharmocopoeia actually worked. Doctors were not yet in the African-American. Why did they have customers? Why did doctors even exist? Why did literally thousands of years of low regulation result in almost no progress? The Romam Empire had low marginal tax rates too, and good security of private property most of the time – why so little progress?

Mostly, as far as I can tell, doctors existed was because people didn’t understand regression to the mean. You go to the doctor when you feel worse than average: after he does something you are eventually closer to average. Or if he did nothing, which was safer. Big pharma started out as frauds – they had nothing better. But being a fraud worked, and it still works. One of my correspondents had an MD tell him that the pharmaceutical industry was rotten to the core, doctoring all kinds of studies, and spinning results. True.

Anyhow, it is surely possible to materially improve the efficacy of drug development, of medical research as a whole. We’re doing better than we did 500 years ago – although probably worse than we did 50 years ago. But I would approach it by learning as much as possible about medical history, demographics, epidemiology, evolutionary medicine, theory of senescence, genetics, etc. Read Koch, not Hayek. There is no royal road to medical progress.

I can never forget the contempt and outrage expressed by doctors when Louis Pasteur had the effrontery to suggest they wash their hands before speeding from a patient dying of a highly communicable disease to a woman giving birth. Talk about killing your patients.

There is an argument that many a man who’s become famous in science isn’t the first discoverer of X, but the last discoverer. What’s meant by “last discoverer” is the person who made X so famous and so undeniable that no one working later than him could be viewed as the discoverer. A famous example sometimes cited is Darwin: he wasn’t the first man to have the idea of evolution, but his book was so packed with evidence, so persuasive and subtle, and indeed so well-written, that nobody after him could plausibly be called the discoverer of evolution. In other words, Darwin was much the most important discoverer of evolution: after Darwin lots of people used the theory snd developed it. (Hayek somewhere remarks that he reckoned that Darwin learned about evolution during his time as an undergraduate at the University of Edinburgh.)

How about Semmelweiss? Was he really the first, or the last, discoverer?

Evolution was already accepted scientific fact by the time Darwin came of age. What he did was propose natural selection as the mechanism of evolution. He was (unless somebody dug up something old) the first to come up with the idea, though not the first to publish, his book was so full specifically because he was ahead of everyone else, he had decades to perfect his book before finally publishing when others started catching on.

Better examples are heliocentrism (stretches back thousands of years), certain aspects of calculus (Limits were developed by Archimedes then forgotten until a recent rediscovery), and the rocket equation (developed by a British physicist in the 19th century but overlooked without the attached concepts of ‘hey we can actually go to space with this’).

In this regard I recall reading a very sad blog by a man whose wife had developed an aggressive form of cancer; he pursued serious study of the condition, its prognoses, forms of treatment (chemo / radiation / surgery) and at the end he came to the discouraged conclusion that it’s mostly a racket.

My elder sister had numbness in two fingers in early 2001. She was quickly diagnosed with a brain tumor whose roots reached far down – the prognosis was ‘six months at the outside’. Nevertheless the family struggled to fight it, mostly with radiation, and she ended up with half her hair burned away and he mind mostly lost – and still died, more or less in line with the first estimate.

There are clearly forms of cancer which can be dealt with successfully – if extending life expectancy by a few years to several decades is understood as ‘success’. Whatever gave rise to that cancer is clearly still in the body and ready to make mischief again, so the question of a ‘cure’ is absurd.

I was diagnosed with an enlarged, but not cancerous, prostate (BPH) eleven years ago. Only in the last 18 months has it emerged as a problem requiring attention: urinary tract infection, pain while peeing, possible complications. The BPH won’t kill me but the complications (kidney infection, nephritis) could well do so. Study has revealed that this is an astonishingly vast medical industry, with a huge variety of treatments. Big money rattles.

The conclusion I reached (also from talking with those who have undergone surgery, and had complications) is that BPH, like cancer, is often an ongoing struggle late in life, with no definitive ‘cure’. It’s dismaying.

I may go for surgery, schoolthought. I am frankly reluctant to do so based on anecdotal evidence from several acquaintances who have suffered complications – one a prosperous German man working with me in Jakarta, but who was operated on in a German hospital. He advised strongly against surgical removal.

A doctor acquaintance of mine at Columbia Univ. earlier this year had his prostate removed without a cutting operation, effected through his urethra, through the magic of microsurgery. He detailed this through a series of emails to an informal maillist to which I belong. Just today he emailed our list about some concert he and his wife attended, so I assume that the operation was a great success. Not myself having this issue, I don’t know whether Dr. Mickey’s operation is generally available. If I were the commenter, I would check this out.

My hunch, that nobody significant seems to be exploring, is that cancer is to a large degree caused by something along the lines of prions–semi-biotic transmissible particles that can spread under the right circumstances from person to person, and are innately impossible to deactivate with current technology.

“Whatever gave rise to that cancer is clearly still in the body and ready to make mischief again, so the question of a ‘cure’ is absurd.”

But cancers aren’t always “caused” by something specific in the body, are they? Like skin cancer: you might be genetically predisposed to get it, but chances increase a lot by getting sunburns every summer – and you could cause it in anyone by exposing them to enough radiation. Take away the cancerous cells completely, and it seems reasonable to talk of a “cure”.

Took me a while to get the gag. ‘Doctors were not yet in the black’, i.e., not yet turning a profit (black here is opposed to red, ‘in the red’, losing money–this is the actual origin of ‘Black Friday’ after Thanksgiving, it was when retailers started making money.)

You hypothesis is ingenious — but still doesn’t make sense in the context. In 1900, doctor’s were obviously ‘in the black’ from a monetary profit and loss point of view. However, I think at that point doctor’s were still killing more people than they saved. So, perhaps doctor’s weren’t yet ‘in the black’ from that point of view.

Thanks, I was having trouble too, Did it mean that there were not enough African American doctors? Their participation being a moral necessity? Or did it mean doctors were not distinguishing that medicine that worked on one group of people was terrible advice for another group? “Only Doctors can kill a man with impunity” — Pliny

“Next, the consequences of failures can be considerably more serious. The equivalent of the blue screen of death is .. death. Developing a new drug is more like developing avionics than apps: we don’t want planes to crash, and we’ve succeeded – but not through a unregulated market. ”

Thank god the state stepped in to stop us buying planes that fall out of the sky!

Otto Lilienthal and other early pioneers of aviation died while experimenting with flight. The Wright brothers almost killed themselves, and one of their passengers did die in one of their early flights.

No. They work for me. Started them in 1985. I think the tricyclics work better than the new drugs, but they have a lot of side effects. (Some people get good results with the new drugs.) If they didn’t work I wouldn’t take them.

I think what you’re seeing is that this is really complicated. I don’t think anyone really understands it completely but there is something real there.

After all, John Snow guessed correctly that cholera was spread by water long before people knew what caused cholera. Progress can be made even if all is not understood.

True. The history of medicine up until 1911 is the history of the placebo effect. In general, four drugs are worthwhile: aspirin, morphine, digitalis, penicillin + variants. I kept asking everyone in my medical school to extend the list, and once got it to about 18 medicines. One medic commented: The highest you will ever get it is 57, which is what the World Health Organization sends out to disaster zone. However, that is only because they are run by a committee.

Guys who transplant trees crumble a couple aspirin into the water in the hole before they shove in the root ball. The acid that makes willows flexible and willowy works on other trees and us. If I was looking for an aspirin replacement I’d look at other willowy weeds and trees for an equivalent acid.

Yes, “diet and exercise” usually accomplishes nothing because it doesn’t lower carbs. Severely lowering carbs and losing down to normal weight apparently just eliminates the metabolic disease in many people.

What about surgery? I’ve been unfortunate enough to have had several of them and, in each case, the surgery delivered exactly as promised. Wouldn’t that count as an area of vast improvement post 1940?De

Same here. Completely torn rotator cuff repaired with some post-space age materials.

Skull reconstruction surgery seems to have advanced in recent decades. The first example I recall was a passenger in the Long Island Railroad massacre in the early ’90s shot in the head with a 9mm bullet. IIRC the surgeons used some sort of titanium mesh to replace part of his skull, and he looked normal afterwards.

I would treat surgery differently than pharmaceuticals when evaluating the success of modern medicine. Since surgery fixes things in a mechanical way, it is easier to understand what is going on than in the more complicated response of a human body to a chemical. Either the implant put the bone back together, or it didn’t. It is usually much more obvious whether or not it worked. You will notice that medical devices tend to have much smaller sample sizes in clinical trials than drugs do. That is because the experiments have much more power.

Related: I’m still unsure as to whether any of the drugs developed under the soviet union (Selank?Phage therapy?) are any good. My guess is no — I can barely find evidence that these treatments are used at all in modern russia, let alone considered competitive with “real medicine.” Some 20 year olds on reddit insist that Semax and Selank are effective.

I would believe the comments from the people who have used these drugs more than any statistics about them at this stage. If I were diagnosed with terminal cancer, for example, I would not accept chemotherapy which makes your life a living hell, but I would try anything that was used by someone else to treat the same disease who is healthy today and anxious to tell you exactly what he did to achieve the remission or cure he experienced. The web is full of people saying that they survived after their physicians told them there was no hope and they are aching to share their stories. They have nothing to sell, they just want to help others. It would be silly not to pay attention to what they are saying. If something helps one person out of 50 – you may be more like that one person helped than the 49 people who weren’t. As the Brits say – Give it a go.

“chemotherapy” means many different things. A good friend was diagnosed with an indolent form of lymphoma – for years it was kept under control with a form of chemo that merely made him tired one afternoon a week.

My mother had a pill as a prophylactic form of chemo after having bowel cancer removed surgically. Caused some tiredness and loss of sensitivity in her fingers toward the end of the course, but nothing worse.

Similar to regulated medicine there are only a couple of supplements widely-acknowledged to work and they’re all pretty boring: caffeine, creatine, beta alanine, a couple more.

The most promising but speculative supplements are probably the ones with a relatively long history of being used in Ayurvedic or Chinese medicine. They’re probably all useless anyway too, but if they’ve been used for a thousand years they’re probably not going to kill you in too obvious of a way and they might even work.

I’ve tried Bacopa and Ashwagandha– they both have pretty pronounced anxiolytic effects and I /thought/ I felt an improvement in memory while on Bacopa for 3 months. Increases sleep need too much for me, so I stopped taking it.

Then there are supplements people take not because they’re anything special but because the closest legal equivalent to illegal drugs: phenibut is a good replacement for Benzos, phenylpiracetam is a decent workout stimulant, 5-HTP or St. John’s Wort are antidepressants, and ephedra (ephedrine) is poor man’s or trucker’s speed.

Doctors have saved our lives and tried and succeeded in killing us. When my great grandmother was in a coma docs said ‘pull the plug’ she’s gone. We knew she was not. We stayed as long as we could each day with her, my grandmother even smuggled me and my brother into her room so we could sing songs for her.

Her hair fell out, she lost weight, she seemed gone. Then one morning months later she woke up, her hair grew back (black rather than gray!) and she lived a long and healthy life another twenty something years. She died just days short of 100.

My brother clinically died several times. In comas sometimes for weeks. After the first time the docs told us he would die we knew there was hope and he recovered each time they were more sure and each time he survived. He lived another fifteen years.

My mother was given a bad combination in drugs. They killed her liver. The hospital and doctors worked very hard for her to die. They did everything they could to see her die including denying her medication, hydration and food anytime we left for any length of time we had to have family members with her at all times simply to make sure they didn’t kill her. They finally allowed her liver failure to kill her. The admin even changed regulations to make sure she could never qualify for a transplant right in front of us in meetings. It was a nightmare.

The admin was determined to bury a mistake. They finally succeeded.

So yes they can do more than they did but they can also kill you if you are not careful and they will if it is to their advantage.

We thought it was accidental or that they had lots of third world workers who couldn’t follow the charts and assumed it was what they were used to not what they were reading. But it happened too often think be chance. So my daughter and cousin who were RNs would sit with her each day while my wife and sister went through their admin codes to make sure they were following their own (they never were). Several times when confronted with the violations and lies they played it off as if they were doing her a favor.

Back in the days before cable we watched Public TV which meant BBC TV. One show presented murder mysteries. The setup was a dinner party where one guest claimed that no drug had any effect whatsoever. The time period was I think Edwardian. Another character tries to demonstrate that some medicines have some effect by slipping the doubter some laudanum. The doubter then sleeps through the murder and complications ensue.

As I remember the series host said that in the nineteenth century there were only two effective drugs – opium and colchicine.

Reading this post reminded me of Joseph Henrich’s recent book on human culture. I mean, it’s clear the social power of medicine came down to the “cultural module” in the human brain. People are hard-wired to learn from respected elders. This played a role in the evolution of pre-modern medicine in two ways. First, young doctors in training were more likely to accept the assertions of their older colleagues rather than embark on independent exploration of the priors of medicine – even after the scientific method itself developed through cultural evolution. Secondly, regular members of the community were likely to respect doctors as authority figures even though medicine was useless – for exactly the same reason that members of traditional communities believe that witchcraft works. It doesn’t matter if the practice is effective at what appears to be its surface goal. It only matters, on a generational level, that the cultural practice is not so maladaptive that it causes a given culture to fall behind competitor cultures.

Medicine also fills a psychological need–when someone you love is sick, if you put them in the care of a respected doctor, you have visibly done what you could do for them. That makes them, you, and the neighbors feel better, whether or not doctors can do anything about what’s wrong.

Interfluidity has a nice post on this general phenomenon, which he calls “rational astrology”–stuff where there’s a socially accepted thing to do fills a social need, even though it doesn’t make much sense in terms of solving the problem that you claim to be solving. (An example he gives is bond rating agencies–the financial meltdown in 2008 showed that they weren’t doing a very good job, but they still stick around because institutions want some way to define rules about what investments are safe enough.)

Yes but concern for the ill when you have no real knowledge can be harmful. Consider the last day of George Washington. He was feeling poorly so a doctor was called. The doctor bled the ex-president. Another doctor came by and he also bled Washington. He was bled at least four times that day. Washington never rose from his bed again.

Lincoln’s physician probed inside his skull with his finger. He might have died anyway but that dirty finger feeling around in his brain was enough to make sure that he too wasn’t going to rise from his bed either.

There was an article in the FT over the weekend about a medical AI company that claims its diagnoses are 10x more accurate than a physician’s ( https://twitter.com/FTLifeArts/status/820586402161238016 ). Even if that’s widely adopted, you’d still want a physician to talk to. No one wants an app to tell them they’ve got cancer, for example.

I recall a story in the NYT a few years ago about medical schools lightening up the science pre-reqs to let in more women with humanities undergrad degrees. Interesting to reconsider in light of AI.

As Steve Sailer said once, when sick, he’d prefer a Dr. House-style a-hole who can make the best diagnosis. But if a computer can be your Dr. House, maybe that puts more of a premium in bedside manner in physicians.

What we call supplements cannot be tested in large-scale clinical trials against drugs already in use without a huge outlay of money and an actual desire to cure disease using a product that cannot be patented. No major pharmaceutical company is interested in testing such a product.

All of the vitamins are valuable products and most people who take them will tell you that they find that they improve their feeling of well-being. No one asks them and reports on what they say in a medical journal, therefore we are told by the experts that they are useless. People would not continue to buy them if they found them to be useless.

You undoubtedly recall Linus Pauling’s work on vitamin C. He used very high doses of the vitamin intravenously and had good results even against cancer. I just learned recently that when the medical profession “tested” his approach they gave the vitamin by mouth, Such a change in the protocol must have been designed to bring about the failure in the tests that they then published. I understand that some non-M.D. health practitioners are willing to prescribe and oversee exactly the same treatment used by Pauling for patients who request their help, but I have not known anyone who has availed himself of such assistance, so I have no first-hand evidence as to whether it helps or not – but everyone agrees that large doses of vitamin C do no harm compared to the well-known side effects of chemotherapy. It would be useful if one could find a list of medical providers on the web who are willing to prescribe the protocol as used by Dr. Pauling. I assume that the lack of such a list shows that the medical establishment prevents such a list from being published, calling the treatment quackery.

I found on my own that using the sugar xylitol – a substance I learned about on the web – improved a condition that my dentist and a dental pathologist had assured me was not treatable. At my next regular visit my dentist was amazed at the improvement in my mouth. When I told him that I had used xylitol (which is used routinely to prevent caries among children in Finland) he acknowledged that he knew about the substance.

Probably every dentist has heard about xylitol yet no dentist I have ever visited has recommended using this simple and basically free substance to prevent cavities and improve the general health of teeth and gums. The birth of my medical skepticism, in a nutshell.

I am delighted to hear that your dentist uses xylitol on a regular basis with his patients. That is a great achievement. I hope you have told all friends and family about how useful xylitol is in preventing cavities and healing gums.

Interestingly, the most progress in this regard is from the area of “bro-science.” This is where one guy in the gym asks another guy what he is using. “Bro, I’m doing test-e…” Body builders have been willing to experiment on themselves for decades and learned a lot about what works and what does not work. Of course, the results have often been not so good. Still, thanks to meatheads at the gym, we know a lot about how to make a man bigger, faster and stronger.

And lifting. And eating lots of food. There /are/ natural bodybuilders that get tested in and out of competition…And if you don’t believe they’re natural, old-timer strongmen/lifters before synthetic testosterone like John Grimek and Marvin Eder were pretty big and super stromg, though not anywhere near as big as IFBB pros.

To preempt the classic Jayman response by saying it myself: there’s a range of responses to any given workout regimen and a small % are non responders. But most people aren’t and can make some degree of gains!

That is certainly true and should go without saying.
Regarding genetics, should it be wrong to consider that people who follow bodybuilding were/are less prone to be of a blankslatist mind? (From what I can see, discussing someone’s genetics was newer a taboo in these cycles).

I don’t know if it’s the selection effect of being willing and able to stick to such a program, but most big lifting/fitness/coaching personalities I vaguely follow through blogs or books are pretty big on self efficacy and hard work even as they occasionally acknowledge the importance of genetics.

It’s a tough balancing act: if you believe hard work is the biggest factor in progress in weightlifting then it’s tempting to apply that heuristic to all of life.

The class of men who seem to use the most steroids are movie stars. Male action stars all seem to be juicers. Dwayne Johnson (The Rock) essentially trains continuously. He is part Polynesian and seems to fear reverting to his natural chubbiness. The comic book Greek history movie “300” had the whole male cast bare chested so as to show off their “six pack” abdominals.

In my youth the male movie stars could look husky or fit but nothing like modern cinema heroes. People care about baseball players who shoot up androgens but no one seems to care about movie stars. Odd.

Not to mention the many mammograms still being given to women who are more likely to suffer as a result than be helped. How much money was spent on HRT? How much is still being spent on “routine” mammograms? No wonder we can’t pay our medical bills.

No, we know a lot about how to make people bigger faster and stronger from randomized controlled trials and Russians (both for being too stubborn to admit defeat on their theories of speed that eventually panned out once the trick was discovered and because their government was much more amenable to PED research). Bro-science was coined as a derisive term by evidence based fitness people as a term for the silly reasons gym rats come up with for their routines and the tendency to take people who looked like gym rats seriously without consideration for what else they’re doing, or how long they’ve been doing it.

The problem with the herbal supplements game isn’t that some of them are useful, they can be, but what a racket. There is a sucker born every minute and some of them come back multiple times.

I can march into my local herbal drug store and buy a big can of “Andro400” or some such name. I will start losing body fat, I will have more energy, I will feel great. Then the side effects kick in when the hormone levels aren’t as well regulated as they were when I was a young and the body gave me the right dosage all the time.

no thanks.

I can buy incredibly strong marijuana for 1200 dollars a pound in Oregon (over 2000 legal grow houses in one Oregon county, Clackamas county) and bring it back to my home state of Illinois and turn all my fellow retirees into bigger root butted couch potatoes than they already are.

no thanks
I don’t like being stoned, I don’t need the stress of risking jail time, and I don’t need the money. But I have friends and family in that state and it’s nuts. There is no one working in Home Depo during harvest season because they all can make $25 an hour cash cleaning marijuana so they all quit and do that. (At least that was true on the Oregon coast last year.)

Conclusion;

No regulations is worse than over regulated and we are not ever going to find the happy medium because government is terrible and people are stupid. In simpler days maybe laws were made to protect our freedoms. Now they perform two basic functions poorly. They protect the stupid from themselves and the sneaky from the rest of us.

Governments, and society in general, is sort of like a talking jackass. You don’t know whether to condemn it for the stupidity of what it says or just marvel that it can form words.

Without government, and its corollary, religion, at our current population level, we would be killing each other a lot more frequently. More than a few guys have lists just in case “the day” arrives (not me, I’ve mellowed).

I agree. The way I see it is this: the free market is very good at satisfying the customer. In areas where customer satisfaction is the goal in and of itself, this is a good approach. In tech, the customer wants his computer to run fast, he is very good at determining how fast it is, and so the free market will give him a fast computer.

In medicine, of course, he wants to get better, but he is not a good judge of whether or not a treatment actually works. Education, too, is an area where free market reasoning fails. We are told that “school choice” will allow the free market forces to work. But is the goal, maximum customer satisfaction, what we want? No, society wants maximum education of the student body, while students want the best grades for minimum effort, and parents typically will put the premium on grades above all else, parents, furthermore, have a very poor idea of what any given school is actually like. School choice would probably improve certain customer-service aspects of schooling, for instance, by providing busing services to people who live closer to the school, but at the cost of more undeserved grades.

I was diagnosed with T-3 Melanoma, and told that if I didn’t do exactly what the dermatologist and oncologist wanted me to do, it would be fatal. Well, I didn’t do what they wanted, used several “natural” protocols, and most recent test for cancer antibodies came out “normal.”

GC – didn’t you recently have a serious illness? You might try thinking about Raymond Francis’ statement that ALL disease is caused by either toxicity, deficiency, or both (a paraphrase).

You correctly report: “There’s very little regulation of medical developments in third world countries – why aren’t they a a fount of medical progress?”

But really, why not more third-world labs, managed and soon even operated remotely from a comfortable and safe blue-state locale . Big Pharma can work anywhere, so why not where costs are low and regulations minimal or “flexible”. Most of the staff-hours must be by technicians or BS-degree “scientists”, with a few MD-PhD types writing the marching orders and evaluating results. Maybe set up a foreign subsidiary to shelter the home corporation from blame or liability.

Are they worried about weak IP protection offshore?

Is it FDA approval If something works they could ship from offshore or do only the final epidemiological study in the West.

I used to train (martial arts) with a gent who did some sort of quality assurance testing (been a few years so I don’t know exactly what his job was) of pharmaceutical production lines.

Quite a few of them are in India, and sometimes their cleanliness and hygiene standards are not up to ours (clean room technician brought a plastic bucket in with him so he wouldn’t have to go in and out to relieve himself).

Also there are counterfeit drugs being brought in from central/south America.

If the FAA had been around earlier, we might have never gotten planes up in the air in the first place. The Wrights almost killed themselves experimenting with flight, and one of their volunteer passengers did die in a crash. Otto Lilienthal killed himself experimenting with flight, and his work was a major influence on the Wrights.

Psychologists weren’t regulated, but Freudian psychology wasn’t kept alive by the free market, but by cartelized industries like academia and the media.

There is no royal road to progress, because assimilating all the theory in the world will only get you so far. At the end of the day, you need people freely experimenting and willing to potentially kill or maim themselves in the process.

And of course, it did sort of work. Talking about your problems to a sympathetic stranger can make you feel better, at least in the short term. And it gave people an excuse to talk about sex, which is always interesting. Of course, the Freudian theory was complete bullshit, and it certainly wasn’t worth what they paid for it, but at the very least, it probably kept some of them from sticking their heads in the oven, or from getting lobotomies. It may have been like homeopathy in the 1800’s – I mean, it was utterly useless, but it did no harm, compared to bleeding and the other horrific treatments then current. So I suppose it depends on what you mean by “work”.

Makes you wonder what respectable “treatments” we’re going to be laughing about twenty years from now.

In the 1980’s/90’s, John Boyd talked about how many US fighter pilots got killed experimenting with jet fighters in the 1950’s. How it was necessary to really learn what they could do. How pilots aren’t really allowed to do that anymore due to much tighter controls placed on them from higher.

Read Ioannidis. Learn about the countless ways that even the best-intentioned scientists can get it wrong and end up fooling themselves and others.

Greg’s comments about personalized medicine the other day come to mind here, too.

Yes, there’s room for improvement. But fundamentally, progress is slow because this stuff is hard. The science is hard. Figuring out how to organize, fund, evaluate and reward researchers so as to consistently achieve sufficiently rigorous methodology across a vast scope and scale of work is hard.

but maybe they made it harder for themselves with the idea that human populations are the same so a Swedish study is of equal value in Japan and a Japanese study in Sweden?

the Keys example – wanting a single answer to the question of fat vs heart disease so throw out the studies that didn’t conform to his preferred single answer when the more productive path might have been why are the studies from different countries/regions different – maybe the populations are different

The nutrition literature is arguably even noisier than the disease-treatment literature.

But failure to appreciate that there might be relevant genetic variation in study populations is nowhere near the most important problem in the design and analysis of clinical studies today. On the contrary, everybody and his uncle is searching for biomarkers that might stratify populations in an actionable way.

This touches on a thorny problem/feature with markets: they’re great at inducing customer satisfaction, but not so great at giving people what they actually need.

People buy $1K Monster audio cables that listen identically to $20 cables in blind a/b tests. Herbalife has millions of distributors even though their own financials show that more than 90% of distributors lose money. The world is full of companies that objectively produce zero or negative value…but are churning out happy, satisfied customers by the thousand.

I once spoke to a sommelier (sadly, not a pygmy) who argued that it doesn’t matter if wine tasting is a racket and expensive wine tastes the same as cheap wine. It’s not the wine that’s the issue. What you’re paying for is happiness. If you feel like shit drinking wine from a cheap bottle, it makes sense to spend big, regardless of whether or not the extra floral notes exist or are detectable by human olfaction.

It’s an interesting argument, and I sort of see his point. I consider people who practice psychoanalysis or fung shui delusional, but maybe that doesn’t matter. Maybe all that matters is that money flows out and happiness flows in.

You raise interesting points and frame them well, but I nevertheless get a rage on when I look at my pharmaceutical clients in a third-world country making the greater part of their revenue, and mammoth profits, from absolute useless crap: OTC medications like Vicks Vaporub, and ‘energy drinks’, flavored, caffeine-loaded sugar water.

The reason it bothers me (as an accomplice in their swindle) is that it is mothers and wives who blow their tiny savings on this junk, often going without proper foods or new clothes so they can assuage their concerns. Advertising coaxes them along, driving up demand. Markets respond to this demand. Kids become sugar and dairy junkies before they are four years of age. Happily ever after.

Stomach medicine is a big number in Southeast Asian countries. In fact the government and some honest medical professionals tell the public plainly that if they stop stuffing their maws with white rice, gristly fried meat, slimy vegetables cooked to death and sweets they wouldn’t be suffering gastrointestinal disturbances. Doesn’t do any good, as dietary preferences are hard to modify.

Mothers in the kampung implore me to buy cans of condensed milk for their toddlers. When I pointedly point out that shit is 30% sugar, 30% coconut fat (which the infant finds hard to digest) and 40% skim milk (also unncessary for anyone over the age of 4) they bleat ‘But they LIKE it’. How do you answer that.

Consumerism rules; markets respond. Life expectancy is shortened and ailments like diabetes shoot right up. The government on the one hand is trying to expand the number of sugar refineries around the country, to meet growing demand, while their own experts tell them it is a powerfully addictive chemical poisoning the public.

I seem to have misplaced my Kenya-sourced bottle of Lucozade (GSK product). I remember it should help with quite many ailments. Flu and malaria were on the list, among others. I can’t say for sure if I didn’t see dismemberment somewhere in there as well. AIDS, no.

When my daughter was a couple of months old, I used to give her cardboard tubes to play with, like the ones you find inside rolls of paper towels. Fun to wave around and make noises into, plus you can knock over your toys with them. One time I was making a pumpkin pie and spilled a bit of condensed milk on one of the tubes I was saving for her. Not noticing, I gave it to her to play with a little later and she stuck it in her mouth. Couldn’t give her cardboard tubes any more after that, she’d chew them to pieces looking for the sweet spot.

Hail Lustig! Down with the sugar narcotraficantes! Now I read that sugar is also under a cloud of suspicion at a growth factor in malignant tumors.

Actually it was when I was a teenty-bopper in the grim 1950s that Gloria Swanson, whom I idealized after seeing her in the camp SUNSET BOULEVARD, went on the warpath against white sugar. She traveled the world, using her [ancient] fame to awaken the ignorant masses to its perils, mostly without effect (‘food faddist’, ‘health fanatic’ brushoffs).

She should have saved her breath. It was the era of ‘Hey kids! Quick Energy! Free plastic glow-in-the-dark decoder ring in every box of Sugar Deaths!’

Heavy on the meat-dairy-and-eggs in the ‘recommended daily diet’. I’m surprised anyone survived into their sixties. Check out the FDA website; they’re very flamboyant and stalwart on their efforts to combat amphetamine abuse but make no mention of the deleterious effects of the common foods they customarily approve on long-term health.

As another ‘YouTube physician’ put it so succinctly, ‘The food industry is not interested in health and the health industry is not interested in food”. He mentioned this in the context of a large health convention in the South sponsored by – wait for it – a cattlemen’s association!

I agree. I also get very uncomfortable arguing for this when children are involved, or there’s addictive substances in play.

In tech support they talk about “PEBKAC” (Problem Exists Between Keyboard and Chair, a polite way of saying the customer’s an idiot). Scammers suck, but the real problem is that we live in a world full scammer food: ill-informed, statistically innumerate people. I say that as one of them, I used to believe all sorts of stupid things that collapsed after five minutes of Googling, and I assume I still believe a great many of them now.

“Unregulated drug/health markets aren’t nearly as awesome as libertarians make them sound”

does not get you to

“Therefore regulated drug markets must work better”.

No. It’s entirely possible that the unregulated drug/health industry represents a market failure, AND that there is no realistic regulatory regime capable of actually correcting that failure.

Indeed something like this seems to be the case. Look empirically at the FDA, and try to name anything it does which isn’t more harm than good.

Otherwise we end up in a very silly argument, with libertarians saying “the market in my head works better than your regulated reality” and with everybody else saying “wrong, the FDA in my head works better than your market”.

Look empirically at the FDA, and try to name anything it does which isn’t more harm than good. <<

OK, let’s get away from the silly argument in people’s heads. Please give examples of FDA regulatory decisions that have caused more harm than good. Name specific products (drugs or devices), regulatory decisions, and harms, and explain how you know that the harms have occurred or are likely to occur, and why on balance the harms outweigh the benefits of the decision. Show that you understand the FDA’s benefit/harm assessment in those cases and explain, with reference to empirical evidence, why you think it’s wrong. Non-specific arm waving about unwarranted delays and withholding of potentially life-saving products from desperate patients is non-responsive.

The FDA has its problems, but it’s not possible to talk sensibly about what an effective fix might be without an accurate diagnosis. What do you think it is?

Dale Gieringer analysed this in the 80s, his estimate was that the FDA’s regulations (relative the European Union’s regulations) save about 5,000 people per decade while killing 21,000-120,000 people over the same period of time.

Does anyone know if drug approval times have grown shorter or longer since this study was published?

crooks would be the simplest answer but if you imagine some medieval monk herbalist in a monastery somewhere a lot of them would be genuinely trying to cure people – at least the ones they liked

so they’d try every herb they had on everybody just to see – and 95% of the time nothing worked but occasionally it did. those few occasions would stick in the mind and get into the herbalist books even if that cure only worked on one person in twenty (with those symptoms) – cos relatively speaking that was a lot

what if there were 20 ailments x1, x2, x3 etc that all caused a collection of similar symptoms so they were bundled together and the collection of symptoms called “Ague” or something so the ailment is seen as “Ague” when it’s actually one of x1, x2, x3 etc

and then some herb does cure x3 (but not x1, x2, x4 etc)

then if you’re testing it as a cure for Ague then it might only work one time in twenty – which could be put down to chance when it fact it might cure x3 90% of the time (but only x3).

so i wouldn’t be surprised if herbs that were consistently and independently linked to particular ailments over centuries but in modern trials didn’t live up to that reputation did work but only for some people

#

“save about 5,000 people per decade while killing 21,000-120,000 people over the same period of time”

maybe similarly but in reverse giving the cure for x3 to people with x10, x12, x17 kills them off

‘how did herbs get associated with the treatment for certain ailments?’

If we go back to having people on the bottom third of the economic pyramid borderline starved every winter, eating any plants and grubs they can get, we’d get a big sample size for back for herbs and how they affect ailments. It would help if the doctors couldn’t do any better. And if everyone kept their own farm animals and watched what happened when they ate various plants, that would help. Also if you routinely poison your neighbor’s cow during village feuds. Lots of empiric data.

“Nutritional and herbal supplements are barely regulated at all: so by this argument there should be all kinds of medical progress stemming from that area. But it hasn’t happened. supplements are mostly useless, yet people buy them anyhow. ”

Supplements have to be natural. Once you start tinkering with nature, which is how you get innovation, you’re in the realm of drugs. So pretty hard to see how there would be much innovation in the supplement industry.

Supplements don’t have to be “natural”, but they have be part of (or been in) something that was once natural and could, if squinting and looking at it sideways, be considered as part of some human somewhere’s diet. Well, except for the crazy people who eat their couch stuffing. Couch stuff probably doesn’t count. But given the morals evident in that industry I would expect someone to try it with a straight face.

Donald Trump called his 10 year old son a retard to multiple people on the set of his TV show the Apprentice. The poor kid is autistic. Donald thinks his sons’ mental problems were caused by vaccines, not his advanced age, and is now seeking to appoint an anti vaccine conspiracist to head a government commission on vaccine safety and scientific integrity.

Even worse, he actually called his son “Barron”. “Tiffany” and “Donald Jr” were bad enough, but “Barron”‘s the name of a snotty rich kid in a Michael J Fox movie.

The kid’s going to be fucked when he enters high school. So, so fucked. He’ll have to wear a sandwich board saying DEAR BULLIES: PLEASE MAKE OUT INVOICES FOR MY LUNCH MONEY TO TRUMP TOWER, MANHATTAN to keep up with the demand.

Barron goes to Columbia Grammar (founded 1764) on the upper West Side. Not all smart kids but pretty much all rich and not a place where even an unpopular kid would have to worry about being shaken down.

Tom Arnold has a tape of it, but hasn’t released it yet. I don’t know if he will. Other people claim it as well but the tape would be the proof. Trump threatens to sue everybody for everything so that proves nothing .That Tom Arnold claims to have a tape of Trump calling his son a retard doesn’t prove it either. Melania Trump will be living in New York with Barron to keep him out of the public eye. First time I can ever recall that the family of the president has not lived with him in the white house.

I don’t think it matters one whit. What matters is that Trump is on the side of conspiracy idiots who discourage people from taking vaccines.Wackos believe that stuff, not sitting presidents.

That is an astonishing declaration on your part, considering how the man in question (I won’t call him a ‘gentleman’ as that would be stretching it) has been a public figure for over three decades, and during that time has amassed a mammoth reputation as a chronic liar. It’s not like you are dealing with some obscure hayseed congressman from West Dogshit, Oklahoma: Trump lies as easily as he breathes, and then lies again when challenged about it.

It promises to be a delightful interregnum for the media; for those who have to deal with this chiseler, not so much.

Trump could be a good president. Nobody knows. The subject of this thread was people taking medical decisions into their own hands.I though it relevant to the conversation that Trump is on the side of wackos who with little to no evidence think vaccines cause autism. I can’t stand Trump personally but who cares. Some jerks make good presidents. If you think Trump is a swell guy and is honest as the day is long then fine, make an alter to him. Sing songs to his praise, defend him against all the naysayers. But keep me out of political conversations. They are reliably worthless and I am sorry I brushed the subject at all. From now on Trump is a suit in a card game. OK?

1.) Tom Arnold, the now jobless former husband of Roseanne, the Roseanne who hates her former husband and said he was voting for Trump? Egads, how scary that I know who these two are.

2.) I read Melania and the son were moving to DC when he finished school this year.

3.) I don’t want Trump carelessly frightening people about inoculations, but I also don’t know how much parents really are told about the risks of vaccines. Most doctors cavalierly say, “Nothing to worry about.” Is that actually true?

It’s true: the risks are very small nowadays. And as far as I can tell, the vaccine-autism connection simply does not exist. There is no a priori reason why some vaccination couldn’t have such a risk – but then there is no reason why bananas or chocolate couldn’t increase autism risk, either. The question is whether they do, which you determine by running the numbers on a big sample. There’s nothing there, to the best of my knowledge.

Smack up side the head? I think that a having a kid with a serious problem is terribly hard on a parent, and it’s not surprising that they might reach out for an explanation even when we don’t have much of one.

There can only be ‘progress’ when people care about improvement. I think Dr. Cochran has reached the wrong conclusion about supplements – at present, they’re purchased by people who don’t care whether they work, because the people who do care go to doctors. (Who aren’t very good still, but have improved greatly.)

If people cared about improving supplements, they’d likely manage to improve them, especially since there’s likely lots of low-hanging fruit about. Disorganized, unregulated people made major steps in increasing the THC concentration of marijuana, because they cared about it greatly.

I will also note that there are plenty of cases where imposed order and regulation make people a lot less interested in improving. If you start paying people to do something they previously did because they enjoy it, then discontinue the money, they often stop the behavior – because their previous motivations were replaced.

Take any medicine or supplement. If want to find out about any subtle effects (good or bad), the only way we know to do that is to do large trials where we give the drug to lots of people, don’t give it to a bunch of very similar people, and measure the differences in outcomes. This costs a lot of money. The FDA surely imposes more costs, hopefully making the studies harder to game and the manufacturing of the drug less likely to go wrong. But the studies would costs a lot of money and take a lot of time under any regime where we actually wanted to find put the effects of the drug before it went into widespread use.

This isn’t really what your post is about, Greg, but it’s been said that without our epidemic of obesity/overweight, the pharmaceutical companies would be without 75-80% of their market. I do believe this.

Nutritional and herbal supplements are barely regulated at all: so by this argument
there should be all kinds of medical progress stemming from that area.
But it hasn’t happened.

“Nutritional and herbal supplements” are actually (legally) “Dietary Supplements” and have minimal but hard and strict limits on what can be sold under that rubric. The chemical in question must have been at least kinda, sorta part of a human diet somewhere at some time in the past (I don’t recall the exact details). The gist is that you cannot (legally) invent a new compound and call it a nutritional supplement.

supplements are mostly useless,

I think a more accurate formulation of this is that “supplements are usually useless for most people”. If you have have a crap diet your best bet is a better diet, but if you’re eating in a mess hall in Baghdad, the nearest organic grocer is likely to be REALLY unsafe, and a multivitamin might cover any deficiencies you’re encountering.

My wife was prescribed vitamin B12 for memory problems.

Most people get a less than optimal level of sunshine and a little Vitamin D added to their daily routine might have some benefit. Also there is a new study (that is probably wrong, but you never know) that indicates some correlation between autism and vitamin D during pregnancy.

If you’re preggers there’s some stuff it’s useful to add in (this is why folic acid is a federally required additive for bread.

Athletes have different nutritional requirements than couch potatoes. Creatine supplementation helps with sports that require bursts of power.

yet people buy them anyhow.

In the last election there were 4 candidates that people where HIGHLY partisan and enthusiastic about and not one of them was worth pissing on if they were on fire.

Just say’n.

There’s very little regulation of medical developments in third world countries –
why aren’t they a a fount of medical progress? But that’s an unfair comparison:
we know why they’re not.

Do we? Has anyone done a study?

I would say the reason they aren’t a fount of medical progress is the same reason they are third world countries–a mix of poor education, kleptocratic governments, tribalist collectivism etc.

Lots of Indian doctors are achieving success, both at practice and in research…after leaving India and moving to the United States. So there’s more to medical progress than just deregulating the industry, which I think was Greg’s point.

The third world is good for one thing – manufacturing drugs at cents per pill. As far as I can tell 100% of the world’s modafinil comes from two places: Sun Pharma and HAB, both of which are based out of India.

But even then you have to be careful. Every now and then I take modafinil and it does literally nothing. It’s like a placebo. Probably a bad batch.

Creating chemical compounds is relatively simple in retrospect…perhaps that is to which you were referring. But, in the early 1970s, when Herb Boyer and Stanley Cohen pioneered recombinant DNA technology, most would agree that was an earnest scientific accomplishment even by academic standards. This is called biotechnology, but is generally conflated with Pharma colloquially .

That is interesting about modafinil. I need to better research Indian drug regulatory processes.

I’ve created a blog that discusses Pharma, health, and technology. Would love for you to join in on the discussion!

Screwworms. Not nice, and we do need to keep them down to keep our agricultural and tourist trade in operation.

Or suffer the return of third world crap, like whipworm, and everything else.

Further, actual harmful stuff like Oxycodone has been done to make money, and it has done immense damage, yet the docs that allowed it to continue have suffered no punishment, indeed most of the have gotten rich off of the misery.

Free markets routinely fail, and enlightened and firm government intervention is often the only answer.- but hey your typhoid epidemic is somebody else’s problem?

Libertarian philosophy is no sound basis for a society, and indeed yields monsters like Shreek boy.

I find it utterly amazing that nobody who has had a near death experience has not pursued a vendetta against our venal and foolish congreed or the folks who run these criminal extractive outfits.

Why should an economist’s political affiliation matter? Either he has a theory that describes reality, has predictive power – or he doesn’t. It doesn’t matter whether the cat is black or white, as long as it catches mice.

Because so many liberrtarian economists don’t believe in the possibility, let alone probability of market failure.

Now, when we are on the bottom of the Laffer curve, why do so many conswervative economists think cutting taxes will vastly stimulate the demand in the economy sufficient to offset the direct effect of cutting government spending?

If we had put millions of people into something like the wright Brothers first airplane, millions of people would have died. But then, the lives of the wicked should be made brief, and for the rest of us, death will be a relief.

You are confuting progress as being caused by, and not simply coinciding with the period in which regulation took place. Much of the technological progress leading to the explosion of medical progress had already taken place prior to 1900 and was just waiting to happen. Correlation is not cause.

The implication is there when you ask why third world countries are not the fount of medical progress. You admit that it’s an unfair comparison, but make it nonetheless. Admitting to setting up a straw man and knocking it down does not take away from the fact that it has been done. It was perhaps an unconscious rhetorical sleight of hand, but it was still done.
Good writing should not require a magnifying glass to read, or casuistry to defend.

You might enjoy a history of medicine written a few years before the advent of antibiotics, which, if you ask me, are the main important medical advance of the last 100 years.
“Devils, Drugs and Doctors” by Howard Haggard.
Surgical technique is pretty good these days, and cancer treatments are inarguably better than they used to be, but the big advances were things like chloroform, washing your hands, vitamins and the germ theory of disease. The rest, other than antibiotics, was kind of noise.